Uterine prolapse is a condition where the uterus drops downward from its normal position and pushes into or through the vaginal canal. It happens when the muscles and connective tissues that hold the uterus in place become too weak or stretched to do their job. About 40% of women will experience some degree of pelvic organ prolapse in their lifetime, and the condition becomes increasingly common after age 40, with peak rates among women in their 50s through 70s.
How the Uterus Stays in Place
Your uterus is held in position by a system of muscles and connective tissue that work together like a hammock. The main muscular support comes from the levator ani, a group of muscles that form the floor of your pelvis. These muscles hold the pelvic floor closed and provide the lifting force that keeps your organs from descending.
Connective tissue attachments, often called ligaments, anchor the cervix and upper vagina to the pelvic sidewalls. The cardinal and uterosacral connections are the most important of these. Despite being called “ligaments,” these structures are more like flexible sheets of tissue than the tight bands you might picture in a knee or ankle. When either the muscles or these connective tissue connections fail, the uterus loses its support and begins to descend.
Injury to the levator ani muscle is found in 55% of women with prolapse, compared to only 16% of women with normal support. Failure of the connective tissue connections is also strongly linked to prolapse, and when one connection fails, the others tend to follow.
What Causes the Pelvic Floor to Weaken
Vaginal childbirth is the single biggest risk factor. During delivery, the pelvic floor muscles and connective tissues stretch dramatically, and in many women, they never fully recover. First pregnancies cause measurable changes to all parts of the vaginal wall and perineum. Higher parity (having more children) increases risk further.
Age compounds the damage. As estrogen levels drop after menopause, the pelvic tissues lose elasticity and strength. The highest rate of women seeking treatment for symptomatic prolapse is in the 70 to 79 age group, at roughly 19 per 1,000 women. Obesity adds chronic downward pressure on the pelvic floor, and genetics play a role too. Family history of prolapse is an established risk factor, likely because connective tissue quality is partly inherited. Chronic constipation and repeated heavy straining also contribute by increasing pressure inside the abdomen over time.
Stages of Prolapse
Doctors measure prolapse severity using a standardized system called the POP-Q, which grades descent relative to the opening of the vagina (the hymen):
- Stage 0: No prolapse at all.
- Stage 1: The uterus has dropped slightly but remains more than 1 cm above the vaginal opening.
- Stage 2: The lowest part of the uterus sits within 1 cm above or below the vaginal opening.
- Stage 3: The uterus protrudes more than 1 cm beyond the vaginal opening, but the vagina has not completely turned inside out.
- Stage 4: The vagina and uterus are essentially fully everted, meaning they have turned inside out and protrude outside the body.
Many women with stage 1 or even stage 2 prolapse have no symptoms and discover the condition only during a routine exam. Symptoms typically become noticeable at stage 2 or beyond.
What It Feels Like
The most common sensation is a feeling of heaviness, pressure, or fullness in the pelvis, often described as something “falling out.” Some women can feel or see tissue bulging at the vaginal opening, especially after standing for long periods or at the end of the day. The pressure often eases when lying down.
Prolapse rarely affects just one thing. Because the uterus sits between the bladder and the rectum, its descent can pull on neighboring organs and disrupt their function. Urinary symptoms are extremely common: urgency, frequent urination, and leaking urine with coughing or sneezing. Correcting the prolapse, whether with surgery or a pessary, often relieves these bladder symptoms, suggesting the prolapse itself is the cause.
Bowel symptoms are also frequent. Constipation, difficulty emptying the rectum, and in some cases fecal incontinence can all accompany prolapse. Women who have both prolapse and urinary incontinence tend to report worse bowel function and more discomfort overall. Sexual function can be affected too, with some women experiencing discomfort during intercourse or avoiding intimacy because of the bulge.
Pessaries: A Non-Surgical Option
A pessary is a removable silicone device inserted into the vagina to physically support the uterus and hold it in place. Pessaries come in two broad categories: support types and space-occupying types. The choice depends on how far the prolapse has progressed.
Ring pessaries are the most commonly used support type. They work well for stage 1 and stage 2 prolapse and are easy enough for most women to remove and reinsert on their own for cleaning. As prolapse becomes more severe, ring pessaries become less effective. For stage 3 and stage 4 prolapse, a Gellhorn pessary, which is both supporting and space-occupying, tends to work better. The tradeoff is that Gellhorn pessaries are harder to manage independently, so many women need a healthcare provider to remove and clean them periodically.
Pessaries don’t cure prolapse, but they can manage symptoms for years or even indefinitely. They’re a good option for women who want to avoid surgery, aren’t healthy enough for an operation, or are still planning future pregnancies.
Pelvic Floor Muscle Training
Structured pelvic floor exercises, often guided by a specialized physical therapist, can meaningfully reduce prolapse symptoms. A large trial published in The Lancet found that 57% of women who completed a pelvic floor training program reported feeling better at 12 months, compared to 45% in a control group. Perhaps more telling, only 24% of women who did the exercises sought additional treatment within a year, versus 50% of women who didn’t.
The improvements were most pronounced at 6 months, where 52% of the training group felt better compared to just 17% of controls. The benefits persisted at 12 months, though the gap narrowed somewhat. Pelvic floor training works best for mild to moderate prolapse and is often recommended as a first step before considering surgery or a pessary.
Surgical Treatment
When symptoms are significant and conservative measures aren’t enough, surgery is the next option. The two main approaches are removing the uterus (hysterectomy) with repair of the supporting tissue, or preserving the uterus and reattaching it to stronger structures higher in the pelvis (hysteropexy).
A randomized trial comparing vaginal hysteropexy to vaginal hysterectomy found similar outcomes at three years. Treatment failure occurred in about 24% of women who had the uterus-preserving surgery and 36% of those who had a hysterectomy, though this difference was not statistically significant. For women who want to keep their uterus, whether for personal, cultural, or fertility reasons, uterus-sparing surgery is a reasonable choice with comparable results.
Surgical repair can involve the use of mesh to reinforce weakened tissue, but mesh carries its own risks. In one large study of nearly 700 women who had mesh-based repair, the overall complication rate was 22.5%. About 13% experienced early complications like bleeding or blood clots, and 9.4% had mesh-specific problems: erosion of the mesh through the vaginal wall (4.8%), pain during intercourse (2.4%), and mesh shrinkage (1%). Concerns about mesh complications led the FDA to halt the sale of certain transvaginal mesh products in 2019, though mesh placed through abdominal approaches is still widely used.
Reducing Your Risk
Not all risk factors are within your control, but several are. Maintaining a healthy weight reduces the chronic pressure on your pelvic floor. Treating constipation and avoiding prolonged straining during bowel movements helps limit repeated spikes in abdominal pressure. Starting pelvic floor exercises during and after pregnancy can help the muscles recover from the strain of delivery. For women who do heavy lifting regularly, learning to engage the pelvic floor muscles before and during a lift may offer some protection, though this hasn’t been tested in large trials. Weight loss through diet or bariatric surgery has also been suggested as a preventive measure for women already at elevated risk.